Promoting Health Equity through De-Implementation Research

Deimplementation of ineffective and harmful medical practices: a data-driven commentary

Deimplementation is the discontinuation or abandonment of medical practices that are ineffective or of unclear effectiveness, ranging from simply unhelpful to harmful. With epidemiology expanding to include more translational sciences, epidemiologists can contribute to deimplementation by defining evidence, establishing causality, and advising on study design. An estimated 10%-30% of health care practices have minimal to no benefit to patients and should be targeted for deimplementation. The steps in deimplementation are (1) identify low-value clinical practices, (2) facilitate the deimplementation process, (3) evaluate deimplementation outcomes, and (4) sustain deimplementation, each of which is a complex project. Deimplementation science involves researchers, health care and clinical stakeholders, and patient and community partners affected by the medical practice. Increasing collaboration between epidemiologists and implementation scientists is important to optimizing health care delivery.

Racial and Ethnic Differences in Low-Value Care Among Older Adults in a Large Statewide Health System

BACKGROUND

As value-based payment models incorporate both measures of health equity and low-value care (LVC), understanding how LVC varies by race is vital for interventions. Therefore, we measured racial differences in LVC in a contemporary sample.

METHODS

We conducted a cross-sectional analysis of claims from adults ≥ 55 years receiving care at five academic medical centers in California from 2019 to 2021. Our sample included patients who received a service that could be classified as LVC. The primary outcome was whether a service was classified as LVC. Secondary outcomes included clinical categories of LVC (preventive screening, diagnostic testing, prescription drugs, and preoperative testing). We examined associations between race/ethnicity with outcomes using multivariable regression models adjusted for patient characteristics and medical center.

RESULTS

Among 15,720 members who received potentially LVC, non-Hispanic White older adults comprised 59% of the sample, followed by Asian (17%), unknown race (8%), Latino (8%), non-Hispanic Black (5%), other race (2%). In adjusted models, Asian (-4.9 percentage points [pp]; 95% CI -5.9, -3.8 pp), Black (-5.4 pp; 95% CI -8.0, -2.7 pp), and Latino (-2.5 pp; 95% CI -4.6, -0.4 pp) older adults were less likely to receive LVC compared to White older adults, specifically preventive and preoperative services. Asian, Black, and Latino older adults, however, were more likely to receive low-value prescriptions.

CONCLUSIONS

These diverging racial patterns in LVC across different measures likely reflect differential mechanisms, underscoring the need to use clinically specific measures rather than composite measures, which obscure underlying heterogeneity and could lead to potentially harmful and inequity-producing interventions.

The Challenges Associated with Changing Practice: Barriers to Implementing Naturalistic Developmental Behavioral Interventions in ABA Settings

Naturalistic developmental behavioral intervention (NDBI) supports early social communication skills in young autistic children. Given their emphasis on child-led learning opportunities, NDBI is thought to be a socially valid approach to autism early intervention. Applied behavior analysis (ABA) practices could be an ideal setting to increase access to NDBIs for young autistic children; however, current ABA services continue to rely primarily on structured and adult-led approaches to teaching, including discrete trial training (DTT), which have been criticized for their intensity, limitations in skill generalization, and possible harms. Thus, while there is growing interest in translating NDBI into ABA settings, delivering NDBI in these settings may require de-implementing or transitioning away from using DTT approaches with young autistic children. The current study sought to understand the perspectives of ABA providers on the use of NDBI strategies within ABA clinical settings and the factors impacting the transition away from DTT approaches to effectively integrate NDBI. Semi-structured interviews were conducted with 18 ABA frontline and supervising clinicians across several ABA organizations. Rapid qualitative methods grounded in standard content analysis were used to analyze qualitative data. Results indicated that ABA clinicians generally viewed NDBI positively. However, several themes emerged related to the relative ease of using NDBI and DTT; the relative effectiveness of NDBI and DTT; client, caregiver, and staff perceptions of NDBI; and clinical decision-making around who might benefit from NDBI. Barriers to implementing NDBI included the need to unlearn existing DTT strategies, limited training and self-efficacy delivering NDBI, mixed attitudes toward NDBI, and broader systemic issues in the delivery of ABA services. Findings underscore the importance of understanding ABA frontline clinicians' perspectives regarding the implementation of NDBI and suggest the need for more targeted strategies to integrate NDBI strategies in ABA clinical settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-024-01011-2.

Stakeholders' perspectives on disinvestment of low-value healthcare interventions and practices in Malaysia: an online survey

OBJECTIVES

Healthcare disinvestment requires multi-level decision-making, and early stakeholder engagement is essential to facilitate implementation and acceptance. This study aimed to explore the perceptions of Malaysian healthcare stakeholders to disinvestment initiatives as well as identify disinvestment activities in the country.

METHODS

A cross-sectional online survey was conducted from February to March 2023 among Malaysian healthcare stakeholders involved in resource allocation and decision-making at various levels of governance. Response frequencies were analyzed descriptively and cross-tabulation was performed for specific questions to compare the responses of different groups of stakeholders. For free-text replies, content analysis was used with each verbatim response examined and assigned a theme.

RESULTS

A total of 153 complete responses were analyzed and approximately 37 percent of participants had prior involvement in disinvestment initiatives. Clinical effectiveness and cost-effectiveness ranked as the most important criteria in assessment for disinvestment. Surprisingly, equity was rated the lowest priority despite its crucial role in healthcare decision-making. Almost 90 percent of the respondents concurred that a formal disinvestment framework is necessary and the importance of training for the program's successful implementation. Key obstacles to the adoption of disinvestment include insufficient stakeholder support and political will as well as a lack of expertise in executing the process.

CONCLUSIONS

While disinvestment is perceived as a priority for efficient resource allocation in Malaysian healthcare, there is a lack of a systematic framework for its implementation. Future research should prioritize methodological analysis in healthcare disinvestment and strategies for integrating equity considerations in evaluating disinvestment candidates.

Adaption and National Validation of a Tool for Predicting Mortality from Other Causes Among Men with Nonmetastatic Prostate Cancer

BACKGROUND

An electronic health record-based tool could improve accuracy and eliminate bias in provider estimation of the risk of death from other causes among men with nonmetastatic cancer.

OBJECTIVE

To recalibrate and validate the Veterans Aging Cohort Study Charlson Comorbidity Index (VACS-CCI) to predict non-prostate cancer mortality (non-PCM) and to compare it with a tool predicting prostate cancer mortality (PCM).

DESIGN, SETTING, AND PARTICIPANTS

An observational cohort of men with biopsy-confirmed nonmetastatic prostate cancer, enrolled from 2001 to 2018 in the national US Veterans Health Administration (VA), was divided by the year of diagnosis into the development (2001-2006 and 2008-2018) and validation (2007) sets.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Mortality (all cause, non-PCM, and PCM) was evaluated. Accuracy was assessed using calibration curves and C statistic in the development, validation, and combined sets; overall; and by age (<65 and 65+ yr), race (White and Black), Hispanic ethnicity, and treatment groups.

RESULTS AND LIMITATIONS

Among 107 370 individuals, we observed 24 977 deaths (86% non-PCM). The median age was 65 yr, 4947 were Black, and 5010 were Hispanic. Compared with CCI and age alone (C statistic 0.67, 95% confidence interval [CI] 0.67-0.68), VACS-CCI demonstrated improved validated discrimination (C statistic 0.75, 95% CI 0.74-0.75 for non-PCM). The prostate cancer mortality tool also discriminated well in validation (C statistic 0.81, 95% CI 0.78-0.83). Both were well calibrated overall and within subgroups. Owing to missing data, 18 009/125 379 (14%) were excluded, and VACS-CCI should be validated outside the VA prior to outside application.

CONCLUSIONS

VACS-CCI is ready for implementation within the VA. Electronic health record-assisted calculation is feasible, improves accuracy over age and CCI alone, and could mitigate inaccuracy and bias in provider estimation.

PATIENT SUMMARY

Veterans Aging Cohort Study Charlson Comorbidity Index is ready for application within the Veterans Health Administration. Electronic health record-assisted calculation is feasible, improves accuracy over age and Charlson Comorbidity Index alone, and might help mitigate inaccuracy and bias in provider estimation of the risk of non-prostate cancer mortality.

Eliminating health care inequities through strengthening access to care

OBJECTIVE

To provide a research agenda and recommendations to address inequities in access to health care.

DATA SOURCES AND STUDY SETTING

The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government.

STUDY DESIGN

Multi-stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations.

DATA COLLECTION/EXTRACTION METHODS

Through a stakeholder-engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased.

PRINCIPAL FINDINGS

The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti-racist practices (e.g., co-production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access.

CONCLUSIONS

AHRQ is well-positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations.

Deciphering Disparities: The NHLBI Program on Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR)

Despite several ambitious national health initiatives to eliminate health disparities, spanning more than 4 decades, health disparities remain pervasive in the United States. In an attempt to bend the curve in disparities elimination, the National Heart, Lung, and Blood Institute (NHLBI) issued a funding opportunity on Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) in March 2019. Seven implementation research centers and 1 research coordinating center were funded in September 2020 to plan, develop, and test effective implementation strategies for eliminating disparities in heart and lung disease risk. In the 16 articles presented in this issue of Ethnicity & Disease, the DECIPHeR Alliance investigators and their NHLBI program staff address the work accomplished in the first phase of this biphasic research endeavor. Included in the collection are an article on important lessons learned during technical assistance sessions designed to ensure scientific rigor in clinical study designs, and 2 examples of clinical study process articles. Several articles show the diversity of clinical and public health settings addressed including schools, faith-based settings, federally qualified health centers, and other safety net clinics. All strategies for eliminating disparities tackle a cardiovascular or pulmonary disease and related risk factors. In an additional article, NHLBI program staff address expectations in phase 2 of the DECIPHeR program, strategies to ensure feasibility of scaling and spreading promising strategies identified, and opportunities for translating the DECIPHeR research model to other chronic diseases for the elimination of related health disparities.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Identification of Populations at Risk for "Choosing Un-Wisely": A SEER Population-Based Study

BACKGROUND

Since 2016, the Choosing Wisely campaign has recommended against routine axillary surgery in elderly patients with early stage, hormone receptor positive (ER+) breast cancer. The objective was to evaluate factors associated with axillary surgery in breast cancer patients meeting criteria for sentinel lymph node biopsy (SLNB) omission and identify potential disparities.

METHODS

Female patients age ≥70 years with cT1-2N0M0, ER+, HER2-negative breast cancer diagnosed after publication of the Choosing Wisely recommendations, between 2016 and 2019, were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patient demographics and tumor characteristics associated with axillary surgery were analyzed.

RESULTS

Of the 31 756 patients meeting omission criteria, 25 771 (81.2%) underwent axillary surgery. Hispanic ethnicity, median household income between $35,000 and $70,000, treatment in rural areas, poor differentiation, lobular and mixed lobular with ductal histology, T2 tumors, radiation therapy, and systemic therapy were factors associated with receiving axillary surgery on multivariable analysis. In the axillary surgery cohort, a median of 2 (IQR = 2) nodes were examined and 529 (2.1%) patients were found to have 1 or more positive lymph nodes.

DISCUSSION

Among elderly patients meeting Choosing Wisely criteria for SLNB omission, particular racial, ethnic, socioeconomic, and geographic populations may be at increased risk for potential over treatment. Identification of these factors provides specific opportunities for education and implementation of de-escalation of unnecessary procedures.

Testing Theory-Based Messages to Encourage Women at Average Risk for Breast Cancer to Consider Biennial Mammography Screening

BACKGROUND

The US Preventive Services Task Force does not recommend routine annual mammography screening for women aged 40-49 at average risk. Little research has been done to develop theory-based communication interventions to facilitate informed decision-making about reducing potentially low-value mammography screening.

PURPOSE

Evaluate the effects of theory-based persuasive messages on women's willingness to consider delaying screening mammography until age 50 or have mammograms biennially.

METHODS

We conducted a randomized controlled communication experiment online with a population-based sample of U.S. women aged 40-49 (N = 383) who screened to be at average risk for breast cancer. Women were randomly assigned to the following messaging summaries: annual mammography risks in 40s (Arm 1, n = 124), mammography risks plus family history-based genetic risk (Arm 2, n = 120), and mammography risks, genetic risk, and behavioral alternatives (Arm 3, n = 139). Willingness to delay screening or reduce screening frequency was assessed post-experiment by a set of 5-point Likert scale items.

RESULTS

Women in Arm 3 reported significantly greater willingness to delay screening mammography until age 50 (mean = 0.23, SD = 1.26) compared with those in Arm 1 (mean = -0.17, SD = 1.20; p = .04). There were no significant arm differences in willingness to reduce screening frequency. Exposure to the communication messages significantly shifted women's breast cancer-related risk perceptions without increasing unwarranted cancer worry across all three arms.

CONCLUSIONS

Providing women with screening information and options may help initiate challenging discussions with providers about potentially low-value screening.

Deimplementation in the provision of opioid agonist treatment to achieve equity of care for people engaged in treatment: a qualitative study

BACKGROUND

Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic.

METHODS

Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access.

RESULTS

We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers' conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and "thought leaders" who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with "evidence-enough" and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses.

CONCLUSIONS

The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.

Institutionalisation of convergent medical innovation: an empirical study of the MRI-guided linear accelerator in the Netherlands and the United States

Although convergence is a major trend in the development of medical innovations, the implications of the institutionalisation of convergent innovation are understudied. This paper explores how the institutionalisation of convergent innovation affects the organisation of health care, by using operational domains and categories of the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) and the Institutional Readiness (IR) approach respectively. We use an illustrative comparative case study on the institutionalisation of MRI-guided linear accelerator (MR-Linac) technology in the Netherlands and the United States. Empirically, we conducted 66 interviews with different professionals in the health care system around MR-Linac. The findings show that institutionalisation of convergent innovation affects the organisation of health care by: changing the traditional organisation of solving a medical problem, thereby transforming and reorganising work in the health care environment, providing opportunities for individual user development, collective action and cross-sectoral developments, and requiring the additional work of evaluating convergent innovation, including administrative tasks, innovation and research activities within and across institutions. The insights offered are also relevant for understanding convergence in the medical field, and for rethinking medical innovation in general.

A world of choices: preference elicitation methods for improving the delivery and uptake of HIV prevention and treatment

PURPOSE OF REVIEW

Despite the growing availability of effective HIV prevention and treatment interventions, there are large gaps in their uptake and sustained use across settings. It is crucial to elicit and apply patients' and stakeholders' preferences to maximize the impact of existing and future interventions. This review summarizes quantitative preference elicitation methods (PEM) and how they can be applied to improve the delivery and uptake of HIV prevention and treatment interventions.

RECENT FINDINGS

PEM are increasingly applied in HIV implementation research; however, discrete choice experiments (DCEs) have predominated. Beyond DCEs, there are other underutilized PEM that may improve the reach and effectiveness of HIV prevention and treatment interventions among individuals by prioritizing their barriers to engagement and determining which attributes of interventions and delivery strategies are most valued. PEM can also enhance the adoption and sustained implementation of strategies to deliver HIV prevention and treatment interventions by assessing which attributes are the most acceptable and appropriate to key stakeholders.

SUMMARY

Greater attention to and incorporation of patient's and stakeholders' preferences for HIV prevention and treatment interventions and their delivery has the potential to increase the number of persons accessing and retained in HIV prevention and treatment services.

A Policy Approach to Reducing Low-Value Device-Based Procedure Use

Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial

BACKGROUND

Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown.

METHODS

The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems).

DISCUSSION

The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

A call to integrate health equity into learning health system research training

In 2016, the Agency for Healthcare Research and Quality (AHRQ) recommended seven domains for training and mentoring researchers in learning health systems (LHS) science. Health equity was not included as a competency domain. This commentary from scholars in the Consortium for Applied Training to Advance the Learning health system with Scholars/Trainees (CATALyST) K12 program recommends that competency domains be extended to reflect growing demands for evidence on health inequities and interventions to alleviate them. We present real-life case studies from scholars in an LHS research training program that illustrate facilitators, challenges, and potential solutions at the program, funder, and research community-level to receiving training and mentorship in health equity-focused LHS science. We recommend actions in four areas for LHS research training programs: (a) integrate health equity throughout the current LHS domains; (b) develop training and mentoring in health equity; (c) establish program evaluation standards for consideration of health equity; and (d) bring forth relevant, extant expertise from the areas of health disparities research, community-based participatory research, and community-engaged health services research. We emphasize that LHS research must acknowledge and build on the substantial existing contributions, mainly by scholars of color, in the health equity field.

Supporting the Growth of Domestic HIV Implementation Research in the United States Through Coordination, Consultation, and Collaboration: How We Got Here and Where We Are Headed

BACKGROUND

The Ending the HIV Epidemic (EHE) initiative sets a goal to virtually eliminate new HIV infections in the United States by 2030. The plan is predicated on the fact that tools exist for diagnosis, prevention, and treatment, and the current scientific challenge is how to implement them effectively and with equity. Implementation research (IR) can help identify strategies that support effective implementation of HIV services.

SETTING

NIH funded the Implementation Science Coordination Initiative (ISCI) to support rigorous and actionable IR by providing technical assistance to NIH-funded projects and supporting local implementation knowledge becoming generalizable knowledge.

METHODS

We describe the formation of ISCI, the services it provided to the HIV field, and data it collected from 147 NIH-funded studies. We also provide an overview of this supplement issue as a dissemination strategy for HIV IR.

CONCLUSION

Our ability to reach EHE 2030 goals is strengthened by the knowledge compiled in this supplement, the services of ISCI and connected hubs, and a myriad of investigators and implementation partners collaborating to better understand what is needed to effectively implement the many evidence-based HIV interventions at our disposal.

De-implementing low-value care in cancer care delivery: a systematic review

BACKGROUND

Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings.

METHODS

We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care.

RESULTS

Out of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers' behavior, and 1 de-implementation intervention focused on changing the patients' behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias.

CONCLUSIONS

This review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).

Addressing health disparities through implementation science-a need to integrate an equity lens from the outset

There is increasing attention being given to opportunities and approaches to advance health equity using implementation science. To reduce disparities in health, it is crucial that an equity lens is integrated from the earliest stages of the implementation process. In this paper, we outline four key pre-implementation steps and associated questions for implementation researchers to consider that may help guide selection and design of interventions and associated implementation strategies that are most likely to reach and be effective in reducing health disparities among vulnerable persons and communities.

"It's good to feel like you're doing something": a qualitative study examining state health department employees' views on why ineffective programs continue to be implemented in the USA

Background

Mis-implementation, the inappropriate continuation of programs or policies that are not evidence-based or the inappropriate termination of evidence-based programs and policies, can lead to the inefficient use of scarce resources in public health agencies and decrease the ability of these agencies to deliver effective programs and improve population health. Little is known about why mis-implementation occurs, which is needed to understand how to address it. This study sought to understand the state health department practitioners’ perspectives about what makes programs ineffective and the reasons why ineffective programs continue.

Methods

Eight state health departments (SHDs) were selected to participate in telephone-administered qualitative interviews about decision-making around ending or continuing programs. States were selected based on geographic representation and on their level of mis-implementation (low and high) categorized from our previous national survey. Forty-four SHD chronic disease staff participated in interviews, which were audio-recorded and transcribed verbatim. Transcripts were consensus coded, and themes were identified and summarized. This paper presents two sets of themes, related to (1) what makes a program ineffective and (2) why ineffective programs continue to be implemented according to SHD staff.

Results

Participants considered programs ineffective if they were not evidence-based or if they did not fit well within the population; could not be implemented well due to program restraints or a lack of staff time and resources; did not reach those who could most benefit from the program; or did not show the expected program outcomes through evaluation. Practitioners described several reasons why ineffective programs continued to be implemented, including concerns about damaging the relationships with partner organizations, the presence of program champions, agency capacity, and funding restrictions.

Conclusions

The continued implementation of ineffective programs occurs due to a number of interrelated organizational, relational, human resources, and economic factors. Efforts should focus on preventing mis-implementation since it limits public health agencies’ ability to conduct evidence-based public health, implement evidence-based programs effectively, and reduce the high burden of chronic diseases. The use of evidence-based decision-making in public health agencies and supporting adaptation of programs to improve their fit may prevent mis-implementation. Future work should identify effective strategies to reduce mis-implementation, which can optimize public health practice and improve population health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00252-4.

A scoping review of de-implementation frameworks and models

BACKGROUND

Reduction or elimination of inappropriate, ineffective, or potentially harmful healthcare services and public health programs can help to ensure limited resources are used effectively. Frameworks and models (FM) are valuable tools in conceptualizing and guiding the study of de-implementation. This scoping review sought to identify and characterize FM that can be used to study de-implementation as a phenomenon and identify gaps in the literature to inform future model development and application for research.

METHODS

We searched nine databases and eleven journals from a broad array of disciplines (e.g., healthcare, public health, public policy) for de-implementation studies published between 1990 and June 2020. Two raters independently screened titles and abstracts, and then a pair of raters screened all full text records. We extracted information related to setting, discipline, study design, methodology, and FM characteristics from included studies.

RESULTS

The final search yielded 1860 records, from which we screened 126 full text records. We extracted data from 27 articles containing 27 unique FM. Most FM (n = 21) were applicable to two or more levels of the Socio-Ecological Framework, and most commonly assessed constructs were at the organization level (n = 18). Most FM (n = 18) depicted a linear relationship between constructs, few depicted a more complex structure, such as a nested or cyclical relationship. Thirteen studies applied FM in empirical investigations of de-implementation, while 14 articles were commentary or review papers that included FM.

CONCLUSION

De-implementation is a process studied in a broad array of disciplines, yet implementation science has thus far been limited in the integration of learnings from other fields. This review offers an overview of visual representations of FM that implementation researchers and practitioners can use to inform their work. Additional work is needed to test and refine existing FM and to determine the extent to which FM developed in one setting or for a particular topic can be applied to other contexts. Given the extensive availability of FM in implementation science, we suggest researchers build from existing FM rather than recreating novel FM.

REGISTRATION

Not registered.

A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

BACKGROUND

There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse.

METHODS

This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process.

RESULTS

Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening.

CONCLUSIONS

Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Changes in Health Care Use by Mexican American Medicare Beneficiaries Before and After a Diagnosis of Dementia

BACKGROUND

Evidence from predominantly non-Hispanic White cohorts indicates health care utilization increases before Alzheimer's disease and related dementias (ADRD) is diagnosed. We investigated trends in health care utilization by Mexican American Medicare beneficiaries before and after an incident diagnosis of ADRD.

METHODS

Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare claims files from 1999 to 2016 (n = 558 matched cases and controls). Piecewise regression and generalized linear mixed models were used to compare the quarterly trends in any (ie, one or more) hospitalizations, emergency room (ER) admissions, and physician visits for 1 year before and 1 year after ADRD diagnosis.

RESULTS

The piecewise regression models showed that the per-quarter odds for any hospitalizations (odds ratio [OR] = 1.62, 95% CI = 1.43-1.84) and any ER admissions (OR = 1.40, 95% CI = 1.27-1.54) increased before ADRD was diagnosed. Compared to participants without ADRD, the percentage of participants with ADRD who experienced any hospitalizations (27.2% vs 14.0%) and any ER admissions (19.0% vs 11.7%) was significantly higher at 1 quarter and 3 quarters before ADRD diagnosis, respectively. The per-quarter odds for any hospitalizations (OR = 0.88, 95% CI = 0.80-0.97) and any ER admissions (OR = 0.89, 95% CI = 0.82-0.97) decreased after ADRD was diagnosed. Trends for any physician visits before or after ADRD diagnosis were not statistically significant.

CONCLUSIONS

Older Mexican Americans show an increase in hospitalizations and ER admissions before ADRD is diagnosed, which is followed by a decrease after ADRD diagnosis. These findings support the importance of a timely diagnosis of ADRD for older Mexican Americans.

Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities

Evidence of health disparities affecting newborns abounds. Although quality improvement (QI) methodology is often suggested as a tool to advance health equity, the impact of QI initiatives on disparities is variable. QI work may mitigate, worsen, or perpetuate existing disparities. QI projects designed without an intentional focus on equity promotion may foster intervention-generated inequalities that further disadvantage vulnerable groups. This article reviews disparities in perinatal and neonatal care, the impact of QI on health disparities, and the concept of "Equity-Focused Quality Improvement" (EF-QI). EF-QI differs from QI with an equity lens in that it is action-oriented and centered around equity. EF-QI initiatives purposely integrate equity throughout the fabric of the project and are inclusive, collaborative efforts that foreground and address the needs of disadvantaged populations. EF-QI principles are applicable at every stage of project conception, execution, analysis, and dissemination, and may provide opportunities for reducing disparities in neonatal care.

Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity

Background

Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts.

Methods

Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations.

Results

We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration.

Conclusion

We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact.

Plain language abstract

There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.

Conceptualising Four Categories of Behaviours: Implications for Implementation Strategies to Achieve Behaviour Change

Background: Effectiveness of implementation strategies is influenced by the extent to which they are based on appropriate theories concerning the behaviours that the strategies intend to impact. Effectiveness may be limited simply because the strategies are based on theories that are limited in scope or are derived from partially inaccurate assumptions about the behaviours in question. It may therefore be important to combine insights from various theories to cover the range of influences on the behaviours that will be changed. Aim: This article aims to explore concepts, theories and empirical findings from different disciplines to categorise four types of behaviours and discuss the implications for implementation strategies attempting to change these behaviours. Influences on behaviours: Multilevel influences on behaviours are dichotomized into individual-level and collective-level influences, and behaviours that are guided by conscious cognitive processes are distinguished from those that rely on non-conscious processing. Combining the two dimensions (levels and cognitive modes) creates a 2 x 2 conceptual map consisting of four categories of behaviours. Explicitly conceptualising the levels and cognitive modes is crucial because different implementation strategies are required depending on the characteristics of the behaviours involved in the practise that needs to be changed. Conclusion: The 2 x 2 conceptual map can be used to consider and reflect on the nature of the behaviours that need to be changed, thus providing guidance on the type of theory, model or framework that might be most relevant for understanding and facilitating behaviour change.

Promoting Patient-Centeredness in Opioid Deprescribing: a Blueprint for De-implementation Science

A downward trend in opioid prescribing between 2011 and 2018 has brought per-capita opioid prescriptions below the levels of 2006, the earliest year for which the Centers for Disease Control and Prevention has published data. That trend has affected roughly ten million patients who previously received long-term opioid therapy. Any effort to reduce or replace a prior health practice is termed de-implementation. We suggest that the evaluation of opioid prescribing de-implementation has been misdirected, within US policy and health research, resulting in detrimental impacts on patients, their families and clinicians. Policymakers and implementation scientists can address these deficiencies in how we study and how we perform opioid de-implementation by applying an implementation science framework: the Consolidated Framework for Implementation Research. The Consolidated Framework lays out relevant domains of activity (internal, external, etc.) that influence implementation processes and outcomes. It can deepen our understanding of how policies are chosen, communicated, and carried out. Policymakers and researchers who embrace this framework will need a better approach to measuring success and failure in health care where both pain and opioids are concerned. This would involve shifting from a reductive focus on opioid prescription counts toward measures that are more effective, holistic, and patient-centered.

Better Service by Doing Less: Introducing De-implementation Research in HIV

The course of HIV research has led to a multitude of interventions to prevent and treat HIV. With the arrival of more effective interventions comes the need to end, or de-implement, less effective interventions. PURPOSE OF REVIEW: To describe the state of de-implementation research in HIV and provide a rationale for expanded research in this area. RECENT FINDINGS: Existing studies have identified a set of HIV-specific interventions appropriate for de-implementing and described the persistence of interventions that should be ended. However, to our knowledge, strategies to successfully promote appropriate de-implementation of HIV-specific interventions have not been examined. De-implementing interventions that are no longer needed is an opportunity to improve the quality and effectiveness of HIV services. Opportunities to expand this field of research abound.

Older Women’s Perspectives Driving Mammography Screening Use and Overuse: a Narrative Review of Mixed-Methods Studies

Purpose of Review

Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening.

Recent Findings

The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening.

Summary

Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.

Iterative Decision-making for Evaluation of Adaptations (IDEA): A decision tree for balancing adaptation, fidelity, and intervention impact

BACKGROUND

Evidence-based practices (EBPs) are frequently adapted to maximize outcomes while maintaining fidelity to core EBP elements. Many step-by-step frameworks for adapting EBPs have been developed, but these models may not account for common complexities in the adaptation process. In this paper, we introduce the Iterative Decision-making for Evaluation of Adaptations (IDEA), a tool to guide adaptations that addresses these issues.

FRAMEWORK DESIGN AND USE

Adapting EBPs requires attending to key contingencies incorporated into the IDEA, including: the need for adaptations; fidelity to core EBP elements; the timeframe in which to make adaptations; the potential to collect pilot data; key clinical and implementation outcomes; and stakeholder viewpoints. We use two examples to illustrate application of the IDEA.

CONCLUSIONS

The IDEA is a practical tool to guide EBP adaptation that incorporates important decision points and the dynamism of ongoing adaptation. Its use may help implementation scientists, clinicians, and administrators maximize EBP impact.

Factors Influencing Primary Care Providers' Unneeded Lumbar Spine MRI Orders for Acute, Uncomplicated Low-Back Pain: a Qualitative Study

BACKGROUND

Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded LS-MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures, and cost the US healthcare system about $300 million dollars per year. However, why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood.

OBJECTIVE

To characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Veterans Affairs PCPs identified from administrative data as having high or low rates of guideline-concordant LS-MRI ordering in 2016.

APPROACH

Providers were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. Directed content analysis of transcripts was conducted to identify and compare environmental-, patient-, and provider-level factors contributing to unneeded LS-MRI.

KEY RESULTS

Fifty-five PCPs participated (8.6% response rate). Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns. Low- and high-guideline-concordant providers reported similar patient factors (beliefs in value of imaging and pressure on providers). However, provider groups differed in how provider-level factors (guideline familiarity and agreement, the extent to which they acquiesced to patients, and belief in the value of LS-MRI) contributed to LS-MRI ordering patterns.

CONCLUSIONS

Results describe how diverse environmental, patient, and provider factors contribute to unneeded LS-MRI for acute, uncomplicated low-back pain. Prior research using a single intervention to reduce unneeded LS-MRI has been ineffective. Results suggest that multifaceted de-implementation strategies may be required to reduce unneeded LS-MRI.